Monteggia Fractures Trauma Case for FRCS (Tr & Orth) Oral Examination
1. Describe the appearances shown in these radiographs.
These are AP and lateral radiographs of the elbow that show a fracture of the proximal ulna and a dislocation of the radial head, referred to as a Monteggia fracture dislocation. In this case, the radial head appears to be dislocated anteriorly.
These radiographs show a fracture of the proximal ulna and a dislocation of the radial head, indicating a Monteggia fracture dislocation. In this case, the radial head appears to be dislocated anteriorly.
2. How would you choose to manage this injury?
After obtaining a full history and conducting a thorough examination to identify any neurologic or vascular deficit, I would plan to treat this injury operatively by reducing the radiocapitellar joint and fixing the ulna with plate fixation. The patient would be positioned in a lateral position, injured side uppermost, and the arm would hang over a bar to allow easy access to the dorsal surface. I would use a dorsal approach to the ulna, reduce the fracture, and apply a 3.5 mm LC-DC plate to the ulna. Surgery would be performed with image intensification to confirm the reduction, and the patient would be placed in an above elbow backslab for 2 weeks postoperatively.
Treatment for a Monteggia fracture dislocation with a fracture of the proximal ulna and dislocation of the radial head involves reducing the radiocapitellar joint and fixing the ulna with plate fixation after obtaining a full history and examining the patient for any neurologic or vascular deficits. A dorsal approach to the ulna is used, and a 3.5 mm LC-DC plate is applied to the dorsal surface of the ulna. Surgery is performed with image intensification to confirm the reduction, and the patient is placed in an above elbow backslab for 2 weeks postoperatively.
3. Having reduced and fixed the ulna with plate fixation, you find that the radial head is still dislocated and is irreducible. How would you proceed?
I would screen the elbow dynamically using image intensification to confirm that the radial head is irreducible. I would then examine my fixation of the ulna to ensure it is satisfactory. Malreduction of the ulna is the most common cause for failure to reduce the radiocapitellar joint. If the ulnar fixation appears satisfactory, I would consider whether there may be a soft tissue problem, such as the radial head having buttonholed through a portion of the anconeus, the capsule, or a portion of the annular ligament interposed in the joint. I would address these issues through a separate Kocher’s incision for an open reduction. Reduction may require removal of all or part of the ulnar fixation.
If after reducing and fixing the ulna with plate fixation, the radial head is still dislocated and irreducible, I would screen the elbow dynamically using image intensification to confirm the irreducibility. I would then examine the fixation of the ulna to ensure its satisfactory reduction, as malreduction is the most common cause of failure to reduce the radiocapitellar joint. If I am satisfied with the ulnar fixation, I would consider whether there may be a soft tissue problem, such as the radial head having buttonholed through a portion of anconeus, the capsule, or the interposition of a portion of the annular ligament in the joint. I would perform an open reduction through a separate Kocher's incision to address these soft tissue issues. Reduction may require removal of all or part of the ulnar fixation.
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